2.0 Analysis 2.1 Introduction The helicopter was airworthy prior to impact, and the weather was not considered a factor. The pilot had recently demonstrated that he was competent in autorotations in the AS350B helicopter. Therefore, the analysis will focus on the human and environmental aspects to determine why this accident occurred. 2.2 The Inadvertent Movement of the Fuel Flow Control Lever When a stretcher patient is carried in the Aerospatiale AS350B helicopter, the patient's right knee is close to the fuel flow control lever. The engineer, realizing the potential hazard of bumping the fuel flow control lever, was assisting the patient with the knapsack when the engine lost all power. It could not be determined who inadvertently moved the fuel flow control lever towards the closed position. This action caused fuel starvation to the engine and resulted in a total loss of engine power and a low rotor rpm. 2.3 The Autorotation Although the size of the clearing available was suitable for an autorotation, the uneven surface was not suitable for a run on type landing. When the pilot was faced with the decision to land in the high trees, he made the decision to do a run on autorotation landing in the only clearing available. The nose-high attitude of the helicopter when it struck the ground and the relatively long wreckage trail suggest that the pilot attempted to reduce the airspeed and possibly regain some rotor rpm prior to levelling the helicopter for the landing. The low rotor rpm, which was not recovered prior to ground impact, resulted in a high rate of descent. The combination of low altitude, low rotor rpm, relatively high groundspeed at impact, and the uneven terrain resulted in an autorotation with damage to the helicopter. 3.0 Conclusions 3.1 Findings The fuel flow control lever was accidentally moved out of the flight position, resulting in fuel starvation to the engine and a subsequent loss of all power. The fuel flow lever is not guarded or protected against inadvertent movement. The fuel flow control lever can be moved out of the flight position easily. The combination of low altitude, low rotor rpm, high groundspeed at impact, and uneven terrain resulted in an autorotation with substantial damage to the helicopter. The pilot was certified, trained, and qualified for the flight in accordance with existing regulations. The aircraft was certified, equipped, and maintained in accordance with existing regulations and approved procedures. 3.2 Causes The floor-mounted fuel flow control lever was inadvertently moved to the closed position, resulting in fuel starvation to the engine, a total loss of engine power, and low rotor rpm. 4.0 Safety Action 4.1 Action Taken On 22 September 1994, the TSB forwarded an Aviation Safety Information letter to Transport Canada (TC) regarding the possibility of inadvertent manipulation of the fuel control lever on the AS350B helicopter. TC and industry are investigating the feasibility of installing a control quadrant guard to reduce the likelihood of inadvertent fuel control lever movement.